Disinterested Third Party Continuing Education Affidavit

A disinterested third party is a person not related to the examinee, and not concerned, with respect
to possible gain or loss, in the result of a pending course final examination.  Independent study programs qualify for continuing education only when there is a proctored examination administered
by a disinterested third party, such as a testing center, public library, public school, independent insurance school, college or university and graded by the course provider/vendor.  No examination administered or graded by any insurance company personnel for its own employees will be considered to be administered by a disinterested third party.

NAME OF DISINTERESTED THIRD PARTY:_____________________________________________

DAYTIME ADDRESS OF DISINTERESTED THIRD PARTY:_____________________________

DAYTIME PHONE NUMBER OF DISINTERESTED THIRD PARTY:___________________________

COURSE TITLE:  ________________________________________

COURSE PUBLISHER:  Insurance Schools, Inc.  

DESCRIPTION OF LOCATION WHERE FINAL EXAM IS ADMINISTERED:

__________________________________________________________________________________

TIME FINAL EXAM BEGAN:___________________________ AM / PM

TIME FINAL EXAM ENDED:___________________________ AM / PM

As the disinterested third party, I certify that I had administered the online course examination for:

The examinee completed the examination independently and without the assistance of any study material or advance review of the examination.  No copy was made of the examination.  I, as the disinterested third party, did this day return the Disinterested Third Party Affidavit to the course vendor for grading.

Date:_________   Signature of Disinterested Third Party:____________________________________

I certify that I took the examination independently and without the assistance of any study material or advance review of the examination.  I did immediately, upon completion of the examination, give the  disinterested third party form to: (enter name of disinterested third party here) _____________________________ for mailing to the publisher.  No copy of the examination was made.

Date: ____________   Examinee Print & Sign Name: ____________________\__________________

Examinee's Social Security Number: ____________________________________

Examinee's WV Agent License No.:__________________________________